Chapter 1 An Introduction to Trauma and Health Megan R. Gerber and Emily B. Gerber Introduction: The Case for Trauma-Informed Care Exposure to traumatic events is ubiquitous worldwide and has a well-established del- eterious impact on health. Trauma can take many forms, and its impact varies based on the unique life circumstances, environment and resilience of the impacted indi- vidual. This volume is designed to enable clinicians – notably primary care providers (PCPs), nurses, and their extended care teams – to understand the potential impact of trauma on their patient population and the elements of a trauma- informed care (TIC) response. We believe that TIC is akin to “universal precautions” – front-line clini- cians and health systems do not always know who has experienced, or currently is experiencing, trauma but can respond in an effective, patient-centered manner. The goal of this book is to inform implementation and sustainment of TIC across the individual patient encounter to health systems and communities at large. To lay the groundwork for understanding and implementing TIC, this chapter will provide a broad overview of common forms of interpersonal trauma experienced by patients and the ways in which traumatic experiences impact population health in the US. M. R. Gerber (*) Section of General Internal Medicine, Boston University School of Medicine, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA e-mail: [email protected] E. B. Gerber Kaiser Permanente, San Rafael, CA, USA © Springer Nature Switzerland AG 2019 3 M. R. Gerber (ed.), Trauma-Informed Healthcare Approaches, https://doi.org/10.1007/978-3-030-04342-1_1 4 M. R. Gerber and E. B. Gerber Trauma Defined Broadly defined, the medical definition of trauma refers to “an injury (such as a wound) to living tissue caused by an extrinsic agent, a disordered psychic or behav- ioral state resulting from severe mental or emotional stress or physical injury, an emotional upset” [1]. The word “trauma” is derived from the Greek word for “wound,” and accounts of interpersonal trauma date back to antiquity [2]. Judith Herman in her seminal work, “Trauma and Recovery,” provides historical context leading up to the publication of the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V) [3, 4]. In the late nineteenth century, Pierre Janet and Sigmund Freund provided the first accounts characterizing traumatic events and their clinical implications. Freud’s work on the etiology of hysteria [3] in the twentieth century – notably experiences of psychological and sexual trauma – was met with such a degree of contention and censuring at that time, that contemporary trauma theories and defi- nitions were largely derived from studies of male soldiers’ experiences of war [2, 3]. After World War I, studies of traumatic stress and interventions emerged and then waned to some degree until the advent of the Vietnam war [2]. A shift occurred when society’s attention was drawn to consequences of sexual and domestic violence as a result of the women’s movement of the 1970s [3]. It was then recognized that the most common posttraumatic disorders are not those of war but “of women in civilian life;” Herman describes the history of psychological trauma as “one of episodic amnesia” [3]. This examination of violence and trauma on both the war-related and domestic/interpersonal fronts led to the groundbreaking inclusion of posttraumatic stress disorder (PTSD) in the DSM III in 1980 [5]. Prior to that, the DSM had char- acterized reactions to stressful experiences as “transient situational disturbances” that would wane over time. Subsequently, DSM IV and DSM IV-TR ushered in a more inclusive definition of trauma (including varied events such as car accidents, natural disasters, or learning about the death of a loved one) that resulted in a marked expansion in trauma- related diagnoses [2, 6]. Contemporary theory conceptualizes trauma and responses to it as occurring along a continuum [2, 6]. It is clear that not all persons exposed to even highly traumatic events will go on to develop PTSD [7]; nonethe- less, the experience of that trauma can still have a lasting impact on that individual. The Adverse Childhood Experiences (ACEs) Study It was the landmark work of Felitti and Anda in the Adverse Childhood Experiences (ACEs) Study of the 1990s that ushered in a more mainstream understanding of the impact of childhood trauma on lifelong health [8]. Dr. Vincent Felitti, an internist and Director of Preventive Medicine at Kaiser Permanente, a health maintenance organization (HMO) in California, first made the connection between childhood abuse and adult health during an obesity research study he ran in the 1980s [9]. During a routine checkup, one of his patients mentioned that the year after she was 1 An Introduction to Trauma and Health 5 raped, she gained 105 pounds. Felitti recalled what happened next: “She looked down at the carpet and muttered to herself, ‘Overweight is overlooked. And, that’s the way I needed to be’” [10]. In the obesity clinic at Kaiser, 50% of patients dropped out of treatment. Felitti interviewed these patients and found that a history of child sexual abuse was common [9]. The ACEs Study formally began in 1995 with an initial questionnaire sent to patients who presented for standardized wellness exams at the Kaiser Health Appraisal Clinic. The initial study published in 1998 presented findings for 9,508 participants (eventually over 17,000 were enrolled) – all were insured patients at Kaiser Permanente – and provided groundbreaking evidence linking ACEs to morbidity and mortality in adulthood [8]. The initial study [8] found that patients reporting greater numbers of ACEs had increased risk for smoking, severe obesity, physical inactivity, depressed mood, and suicide attempts. Similar findings occurred for substance use and sexually transmitted infections. The greatest odds, or risk, of disease occurred in those who reported four or more ACEs. The researchers also found a dose–response relationship between the number of ACEs and ischemic heart disease, cancer, chronic bronchitis/emphysema, liver disease, skeletal fractures, and poor overall self-rated health. The initial study population, all insured, was mostly White and middle class. The authors posited that the resulting development of adverse health behaviors, like smoking, led to disease and called for increased communication and coordination across healthcare specialties and enhanced training of providers [8]; this was truly an early call for what we now know as trauma-informed care delivery. Trauma as a Process A traumatic event or series of events results in physiologic changes, complex adapta- tions, and pathways that are linked to adverse health impacts. For example, the hypo- thalamic-pituitary-adrenal (HPA) axis serves as an important mediator after a stressor or under conditions of chronic stress [11]. The HPA axis is responsible for the release of stress hormones, notably glucocorticoids and cortisol. Under normal circumstances, the HPA axis is well-regulated and serves to enable a rapid response to stressful events with prompt return to a normal state. Chronic activation of this system is thought to damage the feedback loops that return stress hormones to their basal, or resting, levels [12, 13]. HPA axis function is determined by a number of factors including genetics, early-life environment [14], and current life stress [15]. The immune system is also involved, and chronic stress can lead to sustained levels of inflammation [13, 16]. An individual’s genetic make-up and environment further modify and contribute to either enhancing or inhibiting these processes. Thus, two people may experience and react entirely differently to the same event objectively characterized as traumatic. We now know that trauma should be conceptualized as a process that is dynamic and involves interaction between an event, or series of events, and the individual (and community’s) level of vulnerability and resilience/protective factors [17]. Understanding resilience and protective factors is important in efforts to aid in pre- vention and recovery. Thus, trauma is less of an event, episode, or exposure and 6 M. R. Gerber and E. B. Gerber more of an interaction that may offer points of intervention, particularly in the healthcare setting. A brief review of the current understanding of factors that medi- ate the “process” of trauma follows. Allostatic Load “Allostasis” refers to the highly integrated balance of the central nervous system (CNS), endocrine/metabolic, and immune systems which mediate the response to stress [11, 13, 18]. As discussed above, prolonged activation of these systems through chronic or repeated exposure to psychosocial stress and traumatic events has damaging consequences or “wear and tear on the body” [13]. The cumulative physiologic consequences of these result in “allostatic load” [11, 18]. Allostatic load is a contributor to cardiovascular disease [11], metabolic disorders [11], and accelerated cognitive decline [19] and has been consistently linked to lower socio- economic status (SES) [11, 12]. Allostatic load is measured in different ways [11]; some studies use biomarkers such as urinary or salivary cortisol and epi- nephrine, while others use clinical measurements like laboratory data, for exam- ple, lipid measurements and hemoglobin A1c. Some studies combine these with measurements of blood pressure, heart rate, body mass index (BMI), or skinfold measurements [11]. Chronic toxic stressors, or traumatic experiences, that occur during childhood, and beyond, can have an enduring influence on allostatic load because they coincide with developmental windows [13], notably those of the brain [20]. ACEs appear to impact allostasis [13], resulting in the observed higher prevalence of disease and premature mortality observed in adulthood [8]. Allostatic load causes ill-health through both the primary biologic impact of stress and damaging behaviors like tobacco and alcohol consumption which are often used as methods of coping with stress [11]. Allostatic load increases with age [11], resulting in longitudinal, wors- ening health impact.